The Obsessive-Compulsive Trap

ONE

Obsessions

Obsessive-compulsive disorder is characterized by two main categories of
symptoms: obsessive thoughts and compulsive behaviors. The terms obsessive and
obsession are used in everyday conversation to suggest a preoccupation. For
example, a person may be described as being obsessed with money. The term obsession
is frequently used to describe a passion or strong interest. For example, “Golf
is Howard’s current obsession.” However, in discussing OCD, the term obsession
is used differently. Obsessions refer to intense thoughts, worries, or images
that are experienced as intrusive and unwanted. These obsessions cause great
anxiety for an individual and often lead to the development of compulsive behaviors
or rituals designed to decrease anxiety. I’ll discuss compulsive behaviors more
in Chapter 2. One of the simplest ways to describe an obsession is an unrealistic
or overexaggerated worry or concern about something. The person experiencing
an obsessive worry will frequently describe a thought or concern that sounds
magnified or “catastrophized” to others. In other words, they will talk about
a fear or worry that is far beyond what most people consider “normal.” In fact
a person with OCD can sometimes tell you that they realize that their fears
or worries are irrational or illogical. However, the anxiety is very real and
overpowering. I’ve talked with many patients who tell me that they know their
worries are irrational; however, they can’t control the overwhelming fear and
anxiety that these obsessive thoughts produce. Obsessions usually fall into
one of several categories.

Contamination Obsessions

These types of obsessions frequently involve excessive concern over germs,
diseases, and other contaminants.

Tammy was a young girl who was fourteen years old when her parents brought
her to me. Her parents indicated that they felt Tammy “worried too much.” Worry
is a common presenting problem for people who suffer from OCD. Tammy’s worries
included fears that something may happen to her parents; fears that something
may happen to her sister; and worry about germs. Tammy was so concerned about
germs; she was unable to use any restroom outside of her home. Traveling was
terrifying for her. Even family vacations that were designed to be fun and stress
free became a source of tremendous anxiety and stress for Tammy and her family.
If the family had to stay in hotels, Tammy would make sure that she brought
several cans of Lysol spray with which she would immediately “disinfect” the
entire hotel room upon arrival. This would enable her to feel “safe” enough
to at least be able to use the restroom. At home, Tammy simply could not use
any public restroom. If she went out with friends to a movie, she made sure
that she would use the restroom just before leaving. During an outing with friends,
she was always careful not to drink too much liquid so she would not have to
urinate. She timed her outings to make sure that she would never be out longer
than she could wait to use the “safe” restroom of her own home. The biggest
challenge she faced was from Monday through Friday at school. While Tammy did
use the restroom before leaving home and restricted her fluid intake, she could
not make it through the entire school day before she had to yield to the call
of nature. Since she could not use the school restroom, she would actually leave
school and return home to use the bathroom. Needless to say, Tammy missed most
of her afternoon classes. In fact, she missed so many of these classes she actually
failed two of them.

While people who suffer from OCD often have a general fear of germs, some
people with OCD have specific fears related to a particular disease. For example,
many people with OCD report a specific fear of contracting AIDS. Most of the
time, these individuals are not in any “high risk” group for contracting HIV
(the virus that leads to the development of AIDS). However, their fear and anxiety
is extraordinary. This fear often causes them to ruminate endlessly that they
may be HIV positive. They are not comforted by reassurance that there is no
reason to believe they should be concerned (e.g., no unprotected sexual encounters;
no blood transfusions; etc.). They begin to describe irrational fears such as
believing that they might have had an undetected cut on their skin (the hand,
for example) and they wonder if they may have shaken hands with someone who
was infected with HIV thus resulting in the transmission of the disease. This
example illustrates the type of thought processes characteristic of obsessive
thinking. Probabilities are greatly exaggerated and logic is stretched to arrive
at the ultimate conclusions. Many of these people will have multiple medical
tests to make sure that they aren’t infected. However, a negative test may lead
to further rumination and obsession. They may begin to wonder, “What if the
test was wrong; after all, they aren’t 100 percent accurate. Perhaps I should
be retested.” Some OCD patients will

receive repeated tests for a disease that they are at virtually zero risk
of contracting. Others will do the opposite: they are so terrified that they
may have the disease they will refuse to receive a test to assuage their fears.
They reason, “If I am HIV positive and find out, I won’t be able to carry on.
It’s better to not know.” While HIV isn’t the only specific disease OCD sufferers
worry about, it is a common one.

Another frequent obsessive worry is that of getting cancer. Jeff was a young
man who read an article about testicular cancer and became terrified that he
would develop this disease. Consequently, he worried almost incessantly about
having the disease. This was a bright young man who functioned at a very high
level. He was at the top of his graduate school class in his studies, and everyone
found him fun to be around. However, he was almost constantly tormented by obsessive
thoughts that he had testicular cancer. He described experiencing “sensations”
in his scrotum. He read that while the disease is often symptom free in the
initial stages, there may be a “heavy feeling” in that area. He began to imagine
that he felt a “heaviness” in this area which further fueled his anxiety and

concern. At times, obsessions can involve an imagined physical sensation.
These are known as somatic obsessions. The only time he was not assaulted by
these thoughts and fears was when he was mentally engaged in a task, or when
he was distracted by something he thoroughly enjoyed. He found that he was almost
anxiety free when he drank alcohol. Consequently, he began to drink more. OCD
can be a precipitant to abuse of substances. Many OCD patients described using
alcohol, marijuana, or other drugs to “self-medicate,” or to decrease the anxiety
caused by the obsessive thoughts.

People who suffer from OCD are particularly at risk of developing obsessive
worries that they may have a disease after reading about the symptoms of a particular
disease. Some OCD sufferers will see a television show or read an article about
an obscure disease or illness and begin to worry that they may have the symptoms
of that malady.

For some people with OCD, the obsessive worry is not of contracting a specific
disease, but rather a pervasive fear of any germs that they may come in contact
with. This may become so extreme that they fear touching doorknobs (because
myriad other people have touched them) or handling money. Their persistent worry
about germs causes anxiety in almost any public arena. Efforts to avoid being
“contaminated” with germs can lead to the development of significant compulsive
behaviors (discussed in Chapter 2).

While some individuals obsess about contracting an illness, others may obsess
about contaminating others. These concerns range from mild (a man who worries
excessively that he will spread germs if he coughs in public) to more severe
(a woman who fears that her past sexual indiscretion may have caused her to
contract a sexually transmitted disease that she will pass on to innocent others
by simply rubbing against them).

Some individuals worry about being contaminated not by germs, but by other
“contaminants.” Many individuals report a fear of being harmed by ordinary household
cleaners. Bobby was a teenage boy who was terrified of household cleaners. When
his mother would spray the kitchen counters with a normal household product,
he would experience severe anxiety (bordering on a panic attack). He avoided
all cabinets and rooms where cleaning supplies were stored.

Other individuals report anxiety over the possibility of environmental contaminants.
These may include chemicals such as pollutants and pesticides. Some individuals
refuse to allow their homes to be sprayed for pests or their lawns to be sprayed
for weeds for fear of being harmed by the toxins used in these types of treatments.

The Need for Symmetry or Exactness

Many people with OCD describe the need for things to be “evened up.” This
refers to the need for things to be symmetrical. For example, some people go
to great extremes to make sure things in their environment are even on each
side. They may arrange their rooms or offices so that things are aligned in
perfect symmetry including pictures on walls, items on their desks, or books
on a shelf. These individuals may also report the need for things to be symmetrical
on their body. I’ve spoken with several individuals who described tying and
retying their shoes in order to make sure they were tied with the exact same
tension on each foot. I worked with a young man who had to make sure that if
he saw something out of the corner of one eye, he also viewed it with the other
eye. This became quite cumbersome as he worked to make sure that things were
always “even.” While these behaviors would be considered compulsive (which we
will discuss in detail in the next chapter), it is the obsessive need for symmetry
that drives the behavior.

A similar type of obsessive thought is the need for exactness. This refers
to a need for certain things to be “just right.” A middle-school student was
failing in classes involving a great deal of writing. This was perplexing to
her parents and teachers since she was such a bright and capable student. She
was originally referred to me in order to see if she suffered from some biologically
based attention problems (such as attention-deficit hyperactivity disorder)
or some type of specific learning disability (such as written expression). I
performed a complete neuropsychological evaluation in order to examine all areas
of cognitive functioning. Testing re-vealed a young woman who was highly intelligent
with achievement scores to match her intellect (indicating no areas of learning
disability). She also manifested no obvious signs of attention difficulties,
and teacher and parent reports indicated no significant difficulties in these
areas. However, in completing the testing, I observed that she took an inordinate
amount of time to complete written tasks. An analysis of her performance determined
that she was obsessed with forming letters on the page perfectly. Her handwriting
was impeccable and letters looked as though they were formed by a printer rather
than a human. She made frequent erasures in her efforts to make the letters
perfect. This need to make her written work perfect caused her to take at least
5 times longer in completing work. This was causing her to miss handing in assignments
at school because she could not complete them in time. Homework became so arduous;
she would become frustrated and quit. This case is an example of how students
who suffer from OCD are often suspected of suffering from other disorders such
as attention-deficit hyperactivity disorder (ADHD) and learning disabilities.

For others, the need for exactness involves positioning things in their environment.
One young woman I worked with described spending hours making sure the fringe
of her oriental rug was “perfectly straight on all sides.” She also described
becoming very anxious if a guest moved one of the pillows on her couch from
its “perfect position.” I had one patient who told me she could not concentrate
on our session until she straightened every diploma and picture on my walls
and lined up the items on my coffee table so they were precisely positioned.

Aggressive Obsessions

Many OCD sufferers are tormented by intrusive fears that they may suddenly
and violently act on angry or violent impulses. Typically, these individuals
have no history of violence or trouble with aggressive behavior. However, they
are terrified that they may suddenly engage in some violent act as though it
is outside of their control. I worked with a woman who became panic stricken
around babies. When I asked her why she was so anxious around infants, she described
with great difficulty the fear that she may suddenly rip the child from the
parents’ arms and slam the child to the ground. This woman was a highly skilled
and very successful paraprofessional. She had no history of any aggressive or
violent behavior in her 40+ years of life. In fact, she loved children and was
deeply saddened that she could not be around her nieces and nephews because
of this paralyzing fear. Her anxiety was completely irrational, and she knew
this. However, she was disturbed that these thoughts were even in her conscious
mind. She described how she was haunted by images of seeing herself being handed
an infant. She talked about how she would see herself raise the small baby above
her head and throw it to the ground with all her might. She then talked about
how she was traumatized by seeing the image of the child lying on the ground,
bleeding and dead from the blow. These images were so gruesome and clear, so
terrifying and traumatic, that they were debilitating to her. She was so horrified
by these thoughts that she went to great lengths to avoid having them. Unfortunately,
this primarily meant avoiding her sister, nieces, and nephews.

I’ve spoken to several individuals who experienced significant anxiety around
knives. In fact, I’ve known a few individuals who had to remove all knives from
their house (which made cooking difficult). If these individuals saw a knife,
they were bombarded by horrific images of taking the knife and sticking it into
their eye. Again, none of these individuals had any history of self-harm. However,
these horrific images and the fear of their possible aggressive impulses were
terrifying.

For others, these obsessions take the form of violent images alone as opposed
to fears of violent impulses. I spoke with a teenager who described riding by
a house on his way to school when he observed a man mowing his yard. The teen
was blindsided by a sudden image of the man falling under the lawnmower and
having his leg severed by the mowing blade. This image was extremely upsetting
to the young man. After this, the teen was unable to ride by the same house
(because of the anxiety this image created for him) and asked his mother to
take him to school via a different and less convenient route.

Many others live with agonizing thoughts and fears of something terrible
happening to loved ones. They may have images or fears of loved ones dying in
motor vehicle accidents or plane crashes. Others may experience extreme anxiety
caused by thoughts of loved ones being attacked and assaulted.

For many, these fears of something terrible happening to loved ones is accompanied
by the belief that if they do something (e.g., recite a certain prayer or engage
in a certain ritual), they can protect the loved ones from harm. The feeling
of responsibility for protecting their loved ones is overwhelming and can cause
great distress.

Religious Obsessions

Because I frequently work with Christians, I see obsessions involving religion
frequently. One of the most common religious obsessions is the fear that the
person has “committed the unpardonable sin.” Others describe the fear that they
have “blasphemed the Holy Ghost.” When asked what they think they may have done
to warrant eternal condemnation, the answers vary. However, they are convinced
that they may have done something to deserve eternal separation from God. Because
of the confusion in the Christian community over this and other religious obsessions
and compulsions, I’ve devoted an entire chapter to this topic (see chapter 5).

Sexual Obsessions

Some people with OCD find any type of sexual thoughts and feelings unacceptable
and extremely anxiety producing. This is particularly true of adolescents suffering
with OCD. Eric was a young man who experienced an episode of sexual acting out
early in his pre-puberty years. The incident was handled appropriately by his
parents and was in the past. However, the teen harbored extraordinary feelings
of guilt and shame over the incident. He later associated any and all sexual
feelings with this incident and had tremendous difficulty accepting his normal
sexual development. He would become extremely distressed upon waking after having
had a nocturnal emission. He also described seeing a television show in his
basement which caused him to become sexually aroused. Because of his difficulty
with accepting his normal sexual feelings, he began to view the T.V. and eventually
the entire basement as “contaminated.” By the time he came to see me, he could
not go into the basement of his own home. In fact, anything that was in the
basement was viewed as “contaminated” and was at risk of contaminating the remainder
of the house. He would not wear his favorite clothing or listen to his favorite
CD’s because they were in the basement.

I recall another young man who was tormented by the fear that he would become
attracted to other males. The curious fact was that he never had the slightest
attraction to other males. In fact, the thought of this actually repulsed him.
However, he was so preoccupied by the fear that he may someday find another
man attractive, he would go to great lengths to avoid establishing any close
relationships with other male friends.

While it is true that some individuals can become obsessed with sexual thoughts
and feelings in an almost addictive way, the type of sexual obsessions I am
referring to here are different. Sexual obsessions associated with OCD refer
to extreme discomfort with normal and healthy sexual thoughts, feelings, and
impulses.

Doubting obsessions

Some individuals with OCD find themselves constantly questioning their own
behaviors. For example, they may wonder if they locked doors or turned off appliances.
I worked with a man who was late for work every day. I don’t mean a few minutes
late, I mean very late. The only reason he wasn’t fired from his job was because
he was a terrific guy and a valued worker. The reason for his tardiness was
his inability to leave the house due to his fears that he may not have unplugged
the coffee pot or closed the garage door. He described returning to the kitchen
repeatedly to make sure the coffee pot was un-plugged. He would also stare for
long periods of time in order to “make sure” it was unplugged. He reasoned that
if he stood and stared long enough, he would surely remember that it was unplugged.
However, after being gone for a few minutes, his doubts would return and he
would have to go and check again. He also described sitting in the driveway
for a prolonged period of time staring at the garage door in order to make sure
it would not somehow reopen. After leaving the house, his doubts would return
and he would have to return to the house in order to check again.

Hoarding Obsessions

Some people with OCD are referred to as “pack rats” because of their inability
to throw anything away. These people will save any and all items (regardless
of how useless they may be). They often realize that they may be running out
of space to store things. However, when they are faced with the need to make
a decision to throw something out, thoughts run through their mind such as,
“What if I need that item some day?” These thoughts are so strong they stop
the individual from being able to discard even useless items. Consequently,
they begin to gather and collect piles of useless junk. Imagine the distress
this causes family members.

“Just So” Obsessions

This last category of obsessions is a bit difficult to describe. However,
if you suffer from OCD, you will know exactly what I am describing. Many people
with OCD feel that certain things must be done in a certain way. They may have
trouble explaining what that way is or why it must be done that way. However,
they know that it must be done “just so.” A man described one such obsession
to me and demonstrated with his hands. He stated that he often had the urge
to take his hands and position them so that the fingers of his left hand touched
the tips of his right hand at precisely the ends of the finger. He stated, “I’m
not sure how I know when they are touching at that particular spot, but it has
to be exact. I know when I’ve done it because it feels right. Then I can stop
and go on to whatever I need to do.” This man was a successful executive for
a Fortune 500 company. He told me that he could do this in a business meeting
and no one had a clue that he was engaging in the behavior. Again, I am describing
an example of a compulsive behavior. However, it is the obsessive thought of
having to have it “just so” that drives the behavior.

These are examples of a few types of obsessions. Obsessions are a hallmark
symptom of OCD. They are thoughts, worries, images, or impulses that torment
the individual and feel out of the person’s control. Typically, obsessions are
irrational and illogical and may be recognized as such by the individual. However,
they cause debilitating anxiety and distress and usually result in the development
of compulsive or ritual behaviors which I will discuss in the next chapter.
It is important to understand obsessions so that the person can recognize when
they are being plagued by obsessive thoughts or images. Identification of these
obsessions is essential to proper understanding, diagnosis and treatment.